Current information for pharmacists about the MassHealth Pharmacy program
Number 7
Pharmacy Facts
February 24, 2005
MassHealth Pharmacy Program
• Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey
Members with Limited Coverage and Other Emergency Situations
In the past we have reminded pharmacists that when, in their opinion, an emergency exists they should call the UMass DUR unit during business hours. If the situation occurs after normal business hours the pharmacist may enter a “3” in the Level of Service Field and dispense an emergency supply of medication. The pharmacist is required to follow these procedures when a member with MassHealth Limited coverage is attempting to get a prescription filled. The pharmacist will receive this message when filling a medication for these members:
PATIENT HAS DRUG COVERAGE FOR ANTIBIOTICS AND EMERGENCY MEDS ONLY. PLEASE CALL DUR (BUSINESS HRS) IF RPH DETERMINES AN EMERGENCY EXISTS, OR USE LEVEL OF SERV CD 3 (AFTER HRS)
An emergency medical condition is defined at 130 CMR 450.105(G) and 42 U.S.C. 1396b(v) as a medical condition with acute symptoms (including severe pain) such that absence of immediate medical attention can reasonably be expected to result in serious jeopardy to health.
MassHealth Drug List – Topical Antifungal Drugs
MassHealth will have new prior authorization (PA) requirements for certain topical anti-fungal drugs effective March 1, 2005. Generic topical antifungals will not require PA.
Effective March 1, 2005, PA will be required for:
Ertaczo (sertaconazole) – PA Exelderm (sulconazole) – PA Fungizone (amphotericin B) – PA Loprox (ciclopirox) cream, gel, lotion, shampoo, solution – PA Mentax (butenafine) – PA Monistat-Derm (miconazole) – PA Naftin (naftifine) – PA Oxistat (oxiconazole) – PA Please remember that the MHDL and its updates can be found at: www.mass.gov/druglist.
Claims Pricing
MassHealth has identified that FDB provided pricing fields for Pfizer products that may have resulted in some providers being underpaid. MassHealth plans to identify and reverse these claims and reprice them with the correct price information. The problem affected some claims with a date of service between 1/1/05 and 1/31/05. MassHealth will reprocess such claims and expects the reprocessing to be completed by 3/22/05. The reversal and re-bill will appear on the same remittance advice.
Patient Location Codes
The POPS system will be edited to prevent erroneous location codes from being entered on pharmacy claims. MassHealth will deny claims when a user enters an LTC location code for a member who does not reside in a qualified LTC facility. We know that there sometimes could be circumstances under which MassHealth systems may not verify that a member has LTC coverage. If you receive a denied claim for an invalid location code and you know that the member is indeed an LTC resident, you may call the ACS help desk at 1-866-246-8503 for an override.
Please direct any questions or comments (or to be taken off of this fax distribution) to Victor Moquin of ACS at 617-423-9830.